Term
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Definition
patient considered the primary data source
information is subjective |
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Term
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Definition
| charts, family members, other health care providers, |
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Term
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Definition
reliable vs inaccurate historian
nurse records person who provided information, notes any discrepancies, identifies other sources (such as previous records) to confim history |
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Term
| componenets of the health history |
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Definition
demographical data
reason for seeking care
history of present illness
location
duration
intensity
quality/description
aggrivating/alleviating factors
pain goal
functioning goal |
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Term
| history of present illness |
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Definition
what/when/where
+
DETAILS
hirtory, meds,
review of systems
psychosocial
lifestyle
occupation
environment |
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Term
| cultural and environmental considerations |
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Definition
cultural factors influence beleifs about health status
some illnesses more common among certain groups
culture affects home and work environment |
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Term
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Definition
gatherin informtaion on heal-promotion practices
identifying patient areas of concern and risk
patient teaching through review of systems |
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Term
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Definition
may have more complex history
tend to have sensory deficits (hearing/vision)
prior lifestyle factors now influencing health |
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